Provider Demographics
NPI:1558964056
Name:PETTITT, MARIE LYNN
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:LYNN
Last Name:PETTITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 ADAM ST
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-1903
Mailing Address - Country:US
Mailing Address - Phone:716-957-2674
Mailing Address - Fax:
Practice Address - Street 1:355 ADAM ST
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-1903
Practice Address - Country:US
Practice Address - Phone:716-957-2674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer